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Topic: Does any one have a list of ALL possible 2ndry Group/Adj codes? (Read 3331 times)

When filing electronic 2ndry claims from an IDTF on a CMS-1500 I typically utilize PR Patient Responsibility and Adjustment code(s) 1 for Deductible Portions, 2 for Co insurance and 3 for Copay. I am also aware of the group codes CO CR OA and PI. My question is are there any other combinations of Group/Adjustment codes? At times I'd like to communicate more accurately to the 2ndry insurance what is going on. For Example, if I know a 2ndry is typically an insurance of 'last resort' how would I code the electronic 2ndry claim to indicate that the Patient is responsible because their coverage terminated with the Primary. Frequently I use CO-45 then PR 1,2 or 3 for typical Copay Co-Ins or Ded that are Patient Responsibility, but I can't find other Group codes to accompany different Adj codes for other circumstances. Thanks in advance for any assistance anyone can provide.

Well, I guess that helps, I can search each payor's website til I find their 'List' seems like they would have standardized this along with the requirements for electronic billing. Thanks for the reply.

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Pay_My_Claims

not sure why you need that, but every system I have ever used had their own adjustment codes and the ability to create your own. Like I bill for DME so we get denials for included in cost of equip. I can use a code specific for that for audit purposes or i can use the 102 (non allowed0 code that is in our system. It really means the same thing. Why would you want a lot of codes that mean the same?? Just varies by the provider??

I agree with Charlene, why would you want these? you should have your own set of internal codes used. I always keep in mind one of my favorite sayings "Good data in is good data out" Meaning the more specific your internal codes are, the better the reports.

I'd think it damn near impossible to standardize these codes since carriers are not required to use the same type of software/database. Nor should we ever expect them to be, as long as the receiving end is NSF we are all good.

Our Practice Management software has some Pre Loaded that are the most common [See initial post]. But I feel like I should better able to describe for example a balance going to a secondary for "Pip Benefits Exhausted" then just the Copay Co-insurance or Deductible ones 'Available' in the Software. It's not like I want all possible combination(s), I figured with the standardization of electronic billing someone would have created a table of Standard codes, but as you earlier indicated, I am mistaken.

Throw away those "loaded" codes. Gear your mind to what I said "Good data in..good data out". Anticipate what the client will WANT. For example, if your office is participating with BCBS but the doctor is thinking of getting out of the network, you will want to run the numbers. With that in mind he will want a total amount of write/off (adjustments) FOR BCBS compared to the total charge. To get that your database would have to be setup to bill at ONE Standard office fee schedule and then adjustments need to be entered PER carrier. Example: CPT XXXXX $200 Billed Charge. BCBS allowable is $179.00 I would create CPT using the OFFICE fee schedule (actual charge) and my adjustment code might look like this: BCBSadj $21.00 I even take it a step further and break out PPO vs. HMO BCBShmo BCBSppo The more specific..the better the reports.

I'm not talking about internal Adjustment codes or descriptions. Only the CO-45 PR 1,2,3 sent electronically to a 2ndry after Primary payment is received. They are not part of the reporting process of the software, nor are they traceable from any usable standpoint. I think I'm not communicating exactly what I mean accurately. Nevermind all. Thanks for your thoughts.

Ahh ok, I gotcha now. But again, these are by payor and would most likely never be standard unless they find a way to make all carriers use the same system.. (not likely)

but out of curiosity..the code's are on the EOB's and there is always a description of the codes used per EOB. You could ac cumulatively create these master lists but again, I'm not seeing the point if the descriptions and codes are on the EOB.

Medicare is the only one that consistently reports these on there EOB's and they aren't a problem. I was more looking for COB issues where the primary is not covering for a 'reason' or like my other example ...looking to alert a Medical insurance that a Primary Auto or PIP insurers benefits are exhausted, w/o forcing it into a category or code that doesn't quite fit. It's not a big deal, just trying to MORE accurately report to 2ndry insurers [electronically] to reduce potential denials for information etc. Thanks all. it was a stumper for me as well, and apparently not all that important to payors. Have a good day - I'll recind my request :-)

Only the CO-45 PR 1,2,3 sent electronically to a 2ndry after Primary payment is received. They are not part of the reporting process of the software, nor are they traceable from any usable standpoint. I think I'm not communicating exactly what I mean accurately. Nevermind all. Thanks for your thoughts.

no no.. don't recind.. <g>

I got it now.. you are talking about the electronic crossovers from Medicare to MSP. One more question.. are you auto payment posting? that could make big difference. On some PM softwares with auto posting it is much more difficult to track the primary denials or eob codes.. I agree however I don't use auto posting, in my opinion they have not perfected that enough for me to want to use it.. If you are however manually posting payments, when you post the primary payment does your system allow for more than one adj code .. hard to explain but for example what I do in a few softwares is enter the primary payment and most softwares will allow for multiple adjustment codes, so for example let's say I have $100 charge, the carrier allows $75 but $25 is denied. I can do the Medicare pmt adjust code and then another code for the $25, generate the secondary, attach the EOB. Now I can run a report based on that adjustment code to track those amounts I'm waiting for secondary response on. I think it will come down to whether your system allows for multiple adjustments per claim. If not you have to rely on the notes section if your PM software has that capability. (tedious I know)

That's just the way I do it, it might not be efficient for you and I hope I somewhat explained it. Sometimes I overdo things because I'm overly organized so I also keep spread sheets to track certain things for my own internal use. I've always had a hard time relying completely on computers <g>